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SAN JOIN COUNTY ENVIRONMENTAL HEALT ..DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Conoco Phillips 30877 David Camile <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1700 Yosemite Ave (209)823-7676 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Manteca CA 95336 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Triangle Environmental,Inc Roy Soffe <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2525 W.Burbank Blvd 818 840 7020 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Burbank CA 91505 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE=$279/FACILITY(use for monitoring equipment,spill buckets,tank sumps,misc.) $279.00 <br /> PIPING REPAIR FEE=$279/FACILITY(use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE=$20 $ <br /> CONSULTATION FEE=$93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE=$93/HOUR $ <br /> SAMPLING INSPECTION FEE=$93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032 (REVISED 01/22/04) <br />